Health Insurance Plan for
INTERNATIONAL
Students
GLOBAL STUDENT FREEDOM
Specially designed for International Students
24JUL2015GSFreedom
Global Benefits Group and TieCare International have been
specializing in the international insurance market for more than 35
years, serving as leading underwriters, developers and distributors of
products and services designed especially for the needs of overseas
workers and international travelers.
GBG underwrites health, life, disability, travel and other specialty
insurances for groups and individuals who are expatriates,
third-country nationals or high net-worth local nationals.
Under our TieCare International brand, we are the leading provider of
health insurance to the international educational community—
with customers in over 50 countries.
As globalization of the world’s economy has continued to accelerate,
GBG has developed a specialized underwriting structure that is
required to meet the needs of this select market niche. This structure
is devoted to one business only: underwriting risks for organizations
and individuals whose life and work transcend geographic
boundaries.
The GBG portfolio of products provides optimum security because it
is supported by a world-class panel comprising some of the largest
and most financially stable underwriters in the world:
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GBG Insurance Limited (rated B++ by A.M. Best Company)
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Chubb Insurance (rated A++)
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General Reinsurance Corporation (rated A++)
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Lloyd’s of London (rated A)
Additionally, GBG partners with a multitude of local insurance
companies around the world when an admitted carrier is required to
meet specific country regulations. TieCare also operates as a Lloyd’s
coverholder.
We are proud to offer this exciting and innovative structure to our
clients. It provides the international marketplace with an
unprecedented and unique combination:
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International expertise
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Dedicated underwriting facility
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Financial security
▪
Responsive customer service
For more information visit www.tiecare.com
Experience and Expertise
in the International Marketplace
GBG STUDENT
HEALTH INSURANCE
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GENERAL FEATURES AND PLAN SPECIFICATIONS
Benefit Maximum $150,000 per Injury or Sickness Annual Maximum $400,000
Deductible ($45 per Injury or Sickness at Student Health Center) $100 per Injury or Sickness Coinsurance 100% of Usual, Resalable & Customary (URC) Charges Medical Evacuation/ Repatriation $60,000
Repatriation of Remains $50,000 Home Country Coverage $500 maximum AD&D $10,000
COVERED MEDICAL BENEFITS
Emergency Hospital Accommodations
Semi-private room and board $1,000 per day, Up to 30 Days Maximum Hospital Miscellaneous Expenses: while Hospital Confined. Benefits will be paid for
services and supplies such as: the cost of operating room; laboratory tests; X-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies.
$500 per day, Up to 30 days maximum. Intensive Care (If medically necessary) $1,525 per day to 8 days maximum,
Payable in lieu of the Hospital Room and Board Expense. Surgeon’s Benefit (Inpatient or Outpatient)
Physician’s fees for surgery. Covered medical expenses will be paid under this Inpatient
benefit; or under the Outpatient surgery benefit, but not for both. $3,000 Maximum Per Policy Period Assistant Surgeon (Inpatient or Outpatient) 25% of Surgeon’s Benefit payable Day Surgery (Outpatient)
In connection with Outpatient day surgery; excluding nonscheduled surgery and surgery performed in a Hospital emergency room, trauma center, Physician’s office, or clinic. Benefits will be paid for services and supplies such as: the cost of the operating room, laboratory tests and X-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies.
$1,000 Maximum Per Policy Period Pre-admission Testing $900 maximum
Network
ENTRY AGE
Coventry/First Health Network in U.S Minimum 12, Maximum 65
INJURY, ACCIDENT AND SICKNESS
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Emergency Room Benefit
Includes the attending Doctor’s charges, X-rays, laboratory procedures, use of the emergency room and supplies. Subject to an additional copay/deductible of $300 per occurrence. If a Plan Participant is admitted to the hospital following visit to the emergency room, the additional deductible is waived.
After the deductible has been satisfied the plan will pay 80% of Reasonable and Customary Charges.
Maternity
(conception must occur while this coverage is in effect) $5,000 maximum for normal delivery, $7,500 for C-section delivery Mental and Nervous Condition (Inpatient) Benefits are payable at 80%. Mental and Nervous Condition (Outpatient) $5,000 maximum per policy year, Maximum of 40 visits per year,
payable at 80%.
Alcoholism/Drug Abuse Treatment The benefits and the maximum amounts are the same as any Sickness. Emergency Dental Expense
1) Performed by a Physician; and
2) made necessary by Injury to Natural Teeth.
Routine dental care and treatment to the gums are not covered.
$500 maximum Radiation Therapy and/or Chemotherapy $1,000 maximum Physiotherapy (Inpatient or Outpatient) $35 per visit, 1 visit/day,
12 visits maximum Durable Medical Equipment
Must be medical equipment prescribed by a Doctor that 1) is primarily and customarily used to serve a medical purpose; 2) can withstand repeated use; and 3) generally is not useful to a person in the absence of Injury.
No benefits will be paid for rental charges in excess of the purchase price.
$1,000 maximum Prescription Drugs (Outpatient) $100 maximum
COVERED MEDICAL EXPENSES (Continued)
Anesthesia Benefit (Inpatient or Outpatient) 25% of Surgeon’s Benefit payable Diagnostic X-rays & Lab services $500 maximum,
Cat Scan, PET Scan or MRI up to $350 additional. Ambulance Service $400 maximum
Physician Visits (Inpatient or Outpatient):
Benefits are limited to one Physician’s visit per day. Benefits do not apply when related to surgery. Covered medical expenses will be paid under the Inpatient benefit or under the Outpatient benefit for Physician’s Visits but not both.
$50 per visit, 1 visit per day, 30 visits maximum Consultant Physician Fees
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BONUS BENEFITS
ATM Safe: Provides lost cash replacement for losses occurring during a
robbery at an ATM. $500
Travel benefits: Lost baggage. Expense reimbursement due to flight delays. $500 maximum benefit ($100 Deductible)
EXCLUSIONS
The Plan Document does not cover any loss resulting from any of the following unless otherwise covered under the Plan Document by Additional Benefits: 1. Suicide, attempted suicide (including drug overdose) self-destruction, attempted self-destruction or intentional self-inflicted Injury while sane or
insane;
2. War or any act of war, declared or undeclared; 3. Voluntary, active participation in a riot or insurrection;
4. Medical expenses resulting from a motor vehicle accident in excess of that which is payable under any other valid and collectible insurance; 5. Organ transplants;
6. Treatment for an Injury or Sickness resulting from the Plan Participant's intoxication or use of illegal drugs or any drugs or medication that is intentionally not taken in the dosage recommended by the manufacturer or for the purpose prescribed by the Plan Participant's Physician; 7. Eligible Expenses for which the Plan Participant would not be responsible in the absence of the Plan Document;
8. Treatment of acne;
9. Charges which are in excess of Usual, Reasonable and Customary charges; 10. Charges that are not Medically Necessary;
11. Charges provided at no cost to the Plan Participant;
12. Expenses incurred for treatment while in Your Home Country in excess of $500;
13. Regular health checkups; routine physical, immunizations or other examination where there are no objective indications or impairment in normal health;
14. Services or treatment rendered by a Physician, Registered Nurse or any other person who is employed or retained by the Participating Organization; or an Immediate Family member of the Plan Participant;
15. Injuries paid under Workers’ Compensation, Employer’s liability laws or similar occupational benefits or while engaging in an occupation for monetary gain from sources other than the Participating Organization;
16. Benefits for enrolling solely for the purpose of obtaining medical treatment, while on a waiting list for a specific treatment, or while traveling against the advice of a Physician;
17. Pre-existing conditions; however a Pre-Existing condition will be covered after the Plan Participant has been continuously insured for 6 months under the same insurance plan;
18. Pregnancy or childbirth, except when conception occurs while covered under the Plan Document; elective abortion; elective cesarean section; or any complications of any of these conditions; pregnancy or childbirth or a dependent when dependent child of an Plan Participant (except for complications arising there from);
19. Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof;
20. Dental care or treatment other than care of sound, natural teeth and gums required on account of Injury resulting from an Accident while the Plan Participant is covered under the Plan Document, and rendered within 6 months of the Accident;
21. Eyeglasses, contact lenses, hearing aids braces, appliances, or examinations or prescriptions therefore; 22. Weak, strained or flat feet, corns, calluses, or toenails;
23. Expenses incurred during a Hospital emergency room visit which is not of an emergency nature;
24. Treatment paid for or furnished under any other individual or group Plan Document, or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government program or facility set up for the treatment without cost to any individual;
25. Injury sustained while taking part in: mountaineering; hang gliding; parachuting; bungee jumping; racing by horse, motor vehicle or motorcycle; snowmobiling; motorcycle/motor scooter riding; scuba diving, involving underwater breathing apparatus, unless PADI or NAUI certified; snorkeling; water skiing; jet skiing; snow skiing; spelunking; parasailing; white water rafting; surfing, unless part of a school credit course; and snowboarding. 26. Practice or play in any amateur, club, intramural, interscholastic, intercollegiate, professional or semi-professional sports contest or competition; 27. Elective or Cosmetic surgery and Elective Treatment or treatment for congenital anomalies (except as specifically provided), except for
reconstructive surgery on a diseased or injured part of the body (Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or Sickness);
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KEY PROVISIONS
This is only a brief summary of key Plan provisions. Please refer to the Policy for complete details.
Benefits are per person per policy coverage period and are based upon medical necessity and emergency. Benefits are payable after deductible at Usual, Customary and Reasonable (UCR) rates, or at Aetna negotiated rates.
Minimum entry age is 12; Maximum entry age is 65.
This policy will cover any emergency conditions except one which has not been stable in the 90 day prior to policy effective date.
Where pre-authorization is required, the insured must obtain it in writing from the Provider and forward to the Insurance Company.
When in doubt as to coverage specifics or whether pre-authorization is required, consult with GBG Assist. Pre-authorization is not required for annual physical or eye exam.Loss of: Benefit: Percentage of
Principal Sum
Accidental Death 100%
Loss of Both Feet or Feet 100%
Loss of Entire Sight of Both Eyes 100%
Loss of One Hand and One Foot 100%
Loss of One Hand and Entire Sight of One Eye 100%
Loss of One Foot and Entire Sight of One Eye 100%
Loss of One Hand or Foot 50%
Loss of Sight of One Eye 50%
Time Period for Loss 90 days
